Basic Information
| Provider Information | |||||||||
| NPI: | 1649887852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHALLER | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078577074 | ||||||||
| FaxNumber: | 3078566459 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078577074 | ||||||||
| FaxNumber: | 3078566459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC017134 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT-1558 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT-1558 | 01 | WY | STATE ISSUED PHYSICAL THERAPY LICENSE | OTHER |